Nursing Client Goals/Desired Nursing Interventions/Actions/Orders I Evaluation

DX/Clinical Outcomes/Objectives Goals Interventions

Problem
Risk for self or Long-Term Goal: Long-Term Interventions: Long-Term: 1.) The client stated that by
other- directed Client will identify 1.) Assist clients to identify precipitants of Evaluation of knowing the way his body feels
violence r/t impulse behaviors dysfunctional mood, differentiating what can and this goal is set when he gets in aggressive
impulsivity and demonstrate cannot be changed. Help them identify available for [date]. The moods, he can to stop and think
and impaired appropriate self- resources and personal strengths. Teach new client has about what his next move is
judgment and control behaviors to problem-solving and coping skills. (Foley, 2010). demonstrated going to be instead of acting out
persuasive refrain from harming Rationale: Knowledge of precipitants helps clients progress on impulse. He also said that he
disregard for self and others by develop strategies to prevent mood changes. toward this knows that instead of punching
the rights of [date]. Using personal strengths and abilities enhances goal by or pushing a peer, he can go to
others AEB feels of control. identifying that the staff to talk about the
risk-taking 2.) Develop a behavioral management plan that is he now knows situation.
behaviors, Short-Term Goal: implemented consistently among all healthcare when he is 2.) The client discussed a time
irritability, Client will displace providers. Communication of rules, expectations, becoming when he did not follow the rules
anger and anger to meaningful and consequences should be addressed as well as angry and during gym time and
aggressiveness, activities, refrain limitations on intrusive, interruptive behaviors. what usually consequentially he lost gym
conflict with from verbal Provide consistent consequences for both desired results when privileges for the rest of the
authority, outbursts, and and undesired behaviors and praise the desired he does not week and did not receive his
history of display no aggressive behaviors (Foley, 2010). control his points for the day. He stated
previous activity [date] Rationale: Consistency about rules and impulses. He that he knows he deserves the
violence, and expectations reduce power struggles and promote has also punishment, and from now on
impulsive, feelings of security for clients. Positive feedback demonstrated he will be patient and follow the
explosive for desired behaviors helps reinforce them. less aggressive rules.
behavior 3.) Have client keep an anger diary and discuss behaviors 3.) The client had just found out
alternative responses together. Teach cognitive towards his about a death in his family, and
behavioral techniques for self- evaluation from the peers during shortly following had an
client (Ackley, & Ladwig, 2008). conflicts. altercation with a peer where he
Rationale: Clients with anger management was shoved. He demonstrated
difficulties may not be aware of changes and cues Short-term: self-control behaviors by
that they are becoming angry or of a time delay in Evaluation of putting his hands up, taking a
the stimulus to their angry response. By using this goal was few steps backward, and
cognitive behavior techniques and reviewing the set for [date]. explaining to the peer why he
diary with staff, the client can identify though The client has was upset and that he did not
processes leading u to anger and the space accomplished want to fight. They both
between the stimulus and response. this goal by apologized and moved on.
using
meaningful
Short-Term Interventions: physical
1.) Identify stimuli that initiate violence and the activities
means of dealing with the stimuli, such as walking whenever he
away. (Ackley, & Ladwig, 2008). gets angry,
Rationale: Assisting the client to identify refraining from
situations and people that upset him provides verbal
information needed for problem solving. The outbursts by
client can then identify alternative responses: explaining his
leaving the stimulus, initiating a distracting feelings first,
activity, or responding assertively rather than and not getting
aggressively. into aggressive 1.) The client verbally
activity. expressed stimuli that triggered
2.) Emphasize that the client is responsible for his his violence: not being able to
choices and behavior. Introduce descriptions of get his way, being wrong,
possible effects of a clients aggressive/violent having everyone tell him what
behavior on others (Ackley, & Ladwig, 2008). to do.
Rationale: In many cases clients operate from a 2.) The client expressed that he
worldview that perceives others as instruments of wants to be able to control his
the clients gratification. Clients must gain that temper and that he knows all of
they are dealing with other human beings who the clients in the facility are
experience pain. Clients behaviors influence how under stress. He stated that
others respond to them. some people clash so it is best to
avoid them or try to decrease
3.) Redirect possible violent behaviors into their triggers as well as his own
physical activities such as doing pushups and sit- to promote a better
ups (Ackley, & Ladwig, 2008). environment.
Rationale: Activities that distract while draining 3.) The client has gone to his
excess energy help to build a repertoire of room to do pushups and sit-ups
alternative behaviors for stress reduction. whenever his temperament has
escalated.
Medical Diagnoses: Anxiety, Change in environment, situational crisis, and stress
Subjective Problem Long Term: Assess the client's A successfully If the clients level
Client Anxiety By a week from level of anxiety met goal of anxiety
states the the date of and physical would be decreases
XXXXX care, reactions to evident by the throughout the
family XXXXXX, the anxiety client being week this
lived client will (tachycardia, able to intervention has
through identify, tachypnea, identify, been successfully
a verbalize, and nonverbal verbalize, and used. If it does not
hurricane demonstrate expressions of demonstrate 4 decrease
and lost techniques to anxiety). Consider techniques to throughout the
their control using The Face control week this
home as anxiety (Ackley Anxiety Scale. (It anxiety. An intervention has
a result & Ladwig, is important to unsuccessfully not been
Family 2008). assess the clients met goal successfully used.
relocated baseline anxiety would occur if If the client
to xxxxx level to determine the client can verbalizes having
6 months if any progress has not do this by used positive self
ago been made to xxxx4, 2xxxx. talk throughout
control anxiety) the week to control
Objective (Ackley & Ladwig, anxiety this
Could 2008). intervention has
include Encourage the been successfully
increased client to use used. If the client
urination positive self-talk does not use
or such as, I can do positive self talk or
diarrhea, this one step at a does not feel the
shortness time, Right now self talk is
of breath, I need to decreasing anxiety
increased breathing levels then the
HR, (Cognitive therapy intervention was
sweating, changes behaviors not successful.
etc. by changing If the client
thoughts. It is verbalizes feeling
important to use additional support
positive self talk and a further
instead of negative decrease in anxiety
self talk) (Ackley levels as the result
& Ladwig, 2008). of back rubs or
Provide backrubs aromatherapy the
or aromatherapy intervention has
for the client to been successful. If
decrease anxiety the touch is not
(Massage and therapeutic to the
aromatherapy can client or
help to decrease aromatherapy does
tension in the not decrease
body, thus anxiety levels, the
decreasing intervention has
anxiety) (Ackley & not been
Ladwig, 2008). successful.
R/T Short Term: If the situational A successfully If the client
Change in By the end of response is met goal is verbalizes an
environment, the date of rational, use shown when increase in self
situational care, xxxxx, empathy to the client can esteem as a result
crisis, and the client will encourage the verbalize her of therapeutic
stress identify and client to interpret symptoms of validation and
verbalize the anxiety anxiety. An conversation this
AEB symptoms of symptoms as unsuccessfully intervention has
Concerns due anxiety (Ackley normal (Validating met goal is if been successful. If
to change in & Ladwig, client feelings the client can the client does not
life events, 2008). promotes self not identify feel an increase in
living esteem, which can her symptoms self esteem this
through a increase quality of of anxiety by intervention has
natural life) (Ackley & the end of the not been
disaster, and Ladwig, 2008). date of care. successful.
relocating Guided imagery If the client
(Ackley & can be used to verbalizes a
Ladwig, decrease anxiety decrease in anxiety
2008). (Guided imagery following guided
can help to imagery this
 decrease tension in intervention has
the body and been successful. If
mind, thus the client does not
decreasing feel a decrease in
anxiety) (Ackley & anxiety after
Ladwig, 2008). guided imagery
Use therapeutic this intervention
touch and healing has not been
touch techniques successful.
(Touch can be
therapeutic and
further encourage
open discussion)
(Ackley & Ladwig,
2008).
 Nursing Client Goals/Desired Nursing *I Evaluation
Assessment DX/Clinical Outcomes/Objectives Interventions/Actions/Orders Goals Interventions
Problem and Rationale
Subjective Problem Long Term: 1.Engage client in individualized * Client able to engage
Unable to obtain Function at maximum communication to maximize in simple
any information Chronic cognitive level client interaction and response conversation
from client confusion 1. communication that involve relating to present
clients interests improves time
communication abilities in those
with dementia above the level
that would normally be expected

Objective
Client unable to
answer simple R/T Short Term: 1.break down self care tasks into * 1.Goal met: client
questions 1. participate in simple steps able to assist during
regarding past Diminished activities of 1. simple verbal prompts can help bath time and
events mental daily living at those with dementia be more participated in
capacity the maximum independent dressing self
Client repeats secondary to of functional 2. decrease stimuli in the 2.goal met: client
questions and dementia ability environment and institute * showed no signs of
unable to retain 2. remain activities associated with pleasant agitation
information content and emotions
free of harm 2. a decrease in stimuli decreases
Extreme of age until agitation
(93) discharge
AEB
Disoriented to Impaired long
place and time term and short
term memory

Medical Diagnoses: Chronic Confusion, Diminished mental capacity secondary to dementia

Medical Diagnoses: Post-trauma Syndrome, Disaster, sudden destruction of ones home and community
Assessment Nursing DX/ Client Goals/ Nursing *I Evaluation
Clinical Problem Desired Interventions/Actions/Orders Goals Interventions
Outcomes and Rationale
Subjective Problem Long Term: Explore and enhance A successfully met If the client can identify
Client states Post-trauma Client will available support systems goal would be support systems and
the xxxx syndrome return to pre- and resources. (Support evident by the community resources,
family lived trauma level of systems and community client returning to the intervention is
through a functioning as resources can encourage her level of successful. If the client
hurricane quickly as communication and can functioning before can not, the
and lost their possible (Ackley reduce isolation) (Ackley & the traumatic intervention has not
home as a & Ladwig, Ladwig, 2008). event. An been successful.
result 2008). Help the client regain unsuccessfully met If the clients sleep and
Family previous sleep and eating goal would be if the eating habits return to
relocated to habit. (Post-trauma client does not what they were before
xxxxx 6 syndrome can impact return to the traumatic event the
months ago sleeping and eating habits, pretrauma intervention is
working to get these areas functioning level. successful, if these
Objective back to pretrauma levels is areas to not return to
Could include key) (Ackley & Ladwig, normal, the
sleep 2008).
disturbances, Help the client use positive intervention was not
vivid cognitive restructuring to successful.
flashbacks, reestablish feelings of self- The intervention would
depression, worth. (Fluctuations and be successful if the
etc. feelings of decreased well- client verbalizes
being can occur due to post- increased feelings of
trauma syndrome) (Ackley self-worth. If the client
& Ladwig, 2008). can not do this, the
intervention has not
been successful.

R/T Short Term: Observe for a reaction to a A successfully met A successfully carried
Disaster, sudden Client will traumatic event in all clients goal would be out intervention would
destruction of ones acknowledge regardless of age or sex. evident by the be if the client can be
home and traumatic event (Post-trauma syndrome can client using open identified as either
community and begin to impact anyone, at any communication to having post-trauma
work with the age) (Ackley & Ladwig, discuss feelings syndrome or not
trauma by 2008). about the hurricane having post-trauma
talking about Provide a safe and that occurred. An syndrome.
AEB the experience therapeutic environment. (A unsuccessfully met If the client verbalizes
Anxiety, flashbacks, and expressing safe, therapeutic goal would be feeling safe in the
and fear (Ackley & feelings of fear, environment will allow the shown if the client environment the
Ladwig, 2008). anger, anxiety, client to feel more at ease does not openly intervention has been
guilt, and talking through the communicate successful. If the client
helplessness a traumatic feelings related to does not feel safe, the
week from the experience) (Ackley & the traumatic intervention has not
date of care, Ladwig, 2008). event. been successful.
xxxxx(Ackley Remain with the client and If the client verbalizes
& Ladwig, provide support during feeling supported
2008). periods of overwhelming during intense
emotions. (Support will emotional periods the
allow the client to feel at intervention has been
ease discussing the successful. If the client
traumatic event) (Ackley & does not feel supported
Ladwig, 2008). the intervention has
Use touch with the client's not been successful.
permission (e.g., a hand on If the client verbalizes
the shoulder, holding a feeling additional
hand). (Touch can be support as the result of
therapeutic to a client, and physical touch the
can further encourage open intervention has been
discussion) (Ackley & successful. If the touch
Ladwig, 2008). is not therapeutic to
the client, the
intervention has not
been successful.
 I

Nursing Client Goals/Desired Nursing Interventions/Actions/Orders Evaluation

DX/Clinical Outcomes/Objectives
Problem Goals Interventions

Chronic low Long Term Long Term Long Term Long Term
self-esteem
r/t impaired Client will verbally 1: Work with client on areas that he or she * Evaluation set for Client states that
cognitive give an accurate and would like to improve using problem-solving [Month] 8, [Year] at he doesnt know of
self-appraisal nonjudgmental account skills. Evaluate need for more teaching in 1400. Client has made areas that he could
AEB of three positive this area. some progress toward improve on. He
negative qualities as well as goal; on [Month] 14, thinks that he has
feedback identify two areas that Rationale: Feelings of low self-esteem can [Year] he was able to reached his
about self he wishes to improve interfere with usual problem-solving abilities identify 2 strengths and maximum
through by [Month] 8, [Year] (Varcarolis, pg 171). did not reject positive self potential. Nursing
clients at 1400. feedback. student worked
statement of, 2: Work with client to identify cognitive with client to
I dont have Short Term distortions that encourage negative self- Short Term identify that he
any good appraisal. focuses on negative
qualities Client will identify one * Goal met. As of [Month] qualities while
and client or two strengths by Rationale: Cognitive 14, [Year] at 1400 client discounting his
seeking [Month] 14, [Year] at was able to identify two positive attributes.
validation. 1400. strengths: being a good Client states that
listener and having good he would like to
communication skills. work on being able
to accept positive
feedback.

distortions reinforce negative, inaccurate Short Term

perception of the world (Varcarolis, pg. 170).
Assessment of
Developing both self-acceptance and self- clients
esteem have been identified as ways to
enhance cognitive interventions (Macinnes,
pg 483).

Short term:

1: Assess existing strengths and coping

abilities, and provide opportunities for their * strengths shows
expression and recognition. that he is very
intelligent and can
Rationale: Supporting a clients beliefs and hold a good
self-rejection and helping them cope can conversation. The
affect self-esteem (Ackley & Ladwig, pg. nursing student
716). worked with the
client to identify
2: Reinforce the personal strengths and his strength in
positive perceptions that the client identifies. communication.

Rationale: Clients with low self-esteem need

to have their existence and value confirmed *
(Ackley & Ladwig, pg. 717).
Medical Diagnoses: Chronic low self-esteem r/t impaired cognitive self-appraisal